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The Choice is Clear

Submit Your Medical History

Family and Social History

Wear glasses* Yes   No Use eye drops (prescription & over the counter?) List: Yes   No
Wear contacts* Yes   No Do you work?
If yes, how many hours per week?
What kind of work do you do? List:
Yes   No
Do you smoke?

Yes   No Do you drink alcohol?
Yes   No
if yes, how much? (packs) If yes, how much?
How long? (years)    
How much do you weigh?    

Do you have difficulty

Yes   No Yes   No Yes   No Yes   No
Yes   No Yes   No Yes   No Yes   No
Yes   No Yes   No Yes   No Yes   No
Yes   No Yes   No Yes   No Yes   No
Yes   No Yes   No Yes   No Yes   No
Yes   No      

Do you currently have any of the following problems: Yes / No

Chronic fever, fatigue, unexpected weight gain/loss Yes   No If Yes, please explain
Ear/nose/throat problems (e.g. hearing loss, sinus infection, sore throat) Yes   No If Yes, please explain
Heart problems (e.g. chest pain, irregular heart beat, high blood pressure, cholesterol) Yes   No If Yes, please explain
Respiratory problems (e.g. shortness of breath, wheezing, coughing, asthma) Yes   No If Yes, please explain
Gastrointestinal problems (e.g. heartburn, abdominal pain, diarrhea, vomiting) Yes   No If Yes, please explain
Urinary problems (e.g. pain or discomfort, blood in urine) Yes   No If Yes, please explain
Skin problems (e.g. rashes, excessive dryness) Yes   No If Yes, please explain
Musculoskeletal problems (e.g. muscle aches, joint pain, swollen joints) Yes   No If Yes, please explain
Neurological problems (e.g. numbness, weakness, headache) Yes   No If Yes, please explain
Psychiatric problems (e.g. depression, anxiety) Yes   No If Yes, please explain
Endocrine problems (e.g. diabetes, thyroid disease) Yes   No If Yes, please explain
Blood problems (e.g. anemia, bleeding tendency) Yes   No If Yes, please explain
Allergies, Hayfever Yes   No If Yes, please explain
Have you ever been exposed to Hepatitis B? Yes   No If Yes, please explain
Have you ever been exposed to Hepatitis C? Yes   No If Yes, please explain
Have you ever tested positive for the HIV Virus? Yes   No If Yes, please explain
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